Development Name	     	
D#	     	
Development Address	     	
Year Construction Started	     	

Instructions: 
•	Complete this form for all federally funded buildings.
•	This is a guide – not a comprehensive reference – for compliance with federal regulations and Minnesota Housing’s Lead-Based Paint Policy regarding reduction of lead-based pain hazards in the rehabilitation of residential rental facilities.
•	For complete applicable federal regulations, refer to the full text at “24 CFR Part 35: Lead-Based Paint Poisoning Prevention in Certain Residential Structures” (the Regulation).
•	Minnesota Housing assumes no responsibility for compliance, and disclaims liability in connection with any non-compliance.

Section 1: Determination of Exemption
Was the property built before 1978?								 Yes	 No

Is this property exempt from the Regulation?							 Yes	 No
If yes, indicate which of the reasons below:

 Rehabilitation will not disturb painted surfaces, and a qualified inspector did not observe any deteriorating            paint during initial visual assessment.
 The property was found by a certified lead-based paint inspector to not have lead-based paint. Attach the Assessment Report.
 All lead-based paint has been identified and removed from the property and clearance has been achieved. Attach evidence of Clearance/Abatement.
 All units in the property are zero-bedroom dwelling units (including efficiencies or single-room occupancy)
 All units are dedicated to elderly housing (i.e., over age 62).
 All units are dedicated to people with disabilities and a child under age 6 is not expected to reside there.
 Repairs are limited to those that are necessary to respond to an emergency as defined in the Regulation.
 Amount of painted surface to be disturbed is below “De Minimis Levels” as defined below. If answer below is yes to all, safe work practices and clearance are not required in that work area.
•	Less than 20 square feet on an exterior surface						 Yes	 No
•	Less than 2 square feet in any single interior room					 Yes	 No
•	Less than 10% of surface area of an interior/exterior component				 Yes	 No

If you answered no to the first question or checked one or more of the exemptions, please sign and date below and submit to Minnesota Housing. If the property is not exempt, please complete the remaining applicable sections and submit to Minnesota Housing before finalizing the scope of work.

I certify that, to the best of my knowledge, the information I have provided is true and accurate.

Owner Signature:  					___________________			Date:                  
Section 2: Determination of Need for Lead-Based Paint Assessment

Will any painted surface above the De Minimis Levels” be disturbed				 Yes	 No
or repaired during the completion of proposed rehabilitation work?
Is the work considered to be “regulated lead work” by the Minnesota Department of Health?	 Yes	 No
Is work expected to exceed $5,000 per unit and lead-based paint is not presumed present?	 Yes	 No
If you answered yes to any of the questions in section 2, a lead-based paint risk assessment must be performed and submitted to Minnesota Housing.
Section 3: Lead-Hazard Evaluation or Presumption of Lead Paint
Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, owners must:
•	Disclose the presence of lead-based paint and/or lead-based paint hazards in the dwelling within 15 calendar days of the date when the owner/applicant receives the evaluation report or makes the presumption that lead-based paint or lead-based paint hazards are present.
•	Provide all tenants the federally approved pamphlets on lead poisoning prevention.
Evaluation method used (check one):
	      Conducted paint testing
        Conducted paint testing and performed risk assessment
        Performed lead hazard screen (in lieu of risk assessment)
        Presumed lead-based paint and/or lead-based paint hazards were present
Date evaluation results were available or date presence of lead-based paint was presumed:      
Do you have a copy of the lead-based paint hazard evaluation report(s)?				 Yes	 No
If yes, please attach.
Do you have a copy of each notice of evaluation  or presumption?				 Yes	 No
As owner of this property, I hereby certify that all of the tenants have been provided with the following information (choose all that apply):
        The notice of evaluation of lead-based paint report within the 15 day deadline
        The HUD pamphlet Protect Your Family from Lead in Your Home
        The EPA pamphlet Renovate Right: Important Lead Hazard Information for Families, Child Care Providers, 
             and Schools (required within 30 days of commencement of rehab)
Will this project receive federal funds?								 Yes	 No
If yes, complete sections 4 and 5 below.

Section 4: Preliminary Determination of Lead Hazard Reduction Strategy
Complete this section only if receiving federal assistance.
Rehabilitation assistance calculation:
	Per unit rehab hard costs: $     
	Per unit federal assistance: $     
Check the appropriate threshold of federal assistance based on your calculation above:
	 ≤ $5,000 per unit		 > $5,000 - ≤ $25,000 per unit		 > $25,000 per unit
Section 5: Lead-Hazard Reduction Method
Hazard reduction method (check one):
     Lead-Safe Work Practices (≤ $5,000 per unit and lead-based paint testing done or lead paint presumed 
          present)
     Interim Controls (> $5,000 - ≤ $25,000 per unit and lead-based paint risk assessment performed)
     Standard Treatments (> $5,000 - ≤ $25,000 per unit and lead-based paint presumed present)
     *Abatement (> $25,000 per unit and lead-based paint risk assessment performed or lead paint presumed
           present)
          *Abatement may not be required if no federal assistance is being used in the project. Please review the         applicable Minnesota Housing Lead-Based Paint Policy.
Will the contractor(s) that will disturb lead-based paint above the “De Minimis Levels”	 Yes	 No	
have the proper certification/training?
Will temporary relocation of occupants be necessary?	Yes	 No	
If yes, please attach a temporary relocation plan.
Certification
I certify that, to the best of my knowledge, the information I have provided is true and accurate.
Owner Signature: ____________________________________________________	Date: